Understanding “the Last 90” in Guyana’s HIV Treatment Cascade: A Facility-Based Assessment of the Viral Loads of Key Populations

Author(s): Reynolds, Z.

Year: 2019

Abstract:

According to the National Guidelines for Management of HIV-Infected and HIV-Exposed Adults and Children (Ministry of Public Health [MOPH], 2015), viral load testing began in Guyana in 2009. It is indicated for adults at six months after initiation of antiretroviral therapy (ART) and every six to 12 months thereafter for clients who are virally suppressed. This supports what the midterm evaluation of Guyana’s HIVision 2020 reports is the ultimate goal of the HIV treatment cascade (the steps a client takes from testing through viral suppression): “viral load suppression” (MOPH, 2017). One strategy outlined in the document is to “increase the proportion of people with HIV (on HAART [highly active antiretroviral therapy]) who have viral load suppression to 90% by 2020.” That strategy is in line with other global goals to ensure that 90 percent of people enrolled in care have a viral load that is below standard limits or even undetectable. Implementing the strategy in Guyana is particularly important in the era of treatment as prevention, to ensure that the virus is undetectable in clients and therefore untransmittable.

The most recent HIV treatment cascade analysis for Guyana, from 2016, reports that 68 percent of people on ART are virally suppressed (MOPH, 2017). These cascade data come from routine reports from health facilities. Although the information is valuable, it is incomplete, because that same cascade reports that 83 percent of clients on ART have a current viral load test.

MEASURE Evaluation—a project funded by the United States Agency for International Development (USAID) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR)—realized that filling this gap would be essential to a full understanding of the HIV cascade in Guyana. If the sample of clients who were missing VL measures could be assumed to represent all clients missing VL measures, then we could leverage estimates of viral suppression from a sample of clients who were missing VL data to obtain a more accurate, representative estimate of viral suppression among a larger population in the care and treatment program. Answering these questions would contribute to USAID’s goal of controlling the HIV/AIDS epidemic and the global 90-90-90 targets that PEPFAR has adopted.

Prior studies in Guyana have shown that the country’s key populations (KPs)—female sex workers (FSWs), men who have sex with men (MSM), and transgender women—face greater barriers to accessing services than the general population does. HIVision 2020 called for the country to pay special attention to KPs (MOPH, 2013). Not only are they engaged in higher-risk activities (National AIDS Programme Secretariat [NAPS] & MEASURE Evaluation, 2014), but also they face greater stigma than other HIV-positive clients. To better understand KPs’ engagement in HIV services and how they compare to non-KP clients, we chose to focus on KPs for this study. NAPS wanted to understand how KPs are progressing along the HIV cascade to viral load suppression.

Our purpose in assessing viral loads among KPs was to estimate the level of HIV viral suppression among KP members who were enrolled in care. We designed the study to (1) quantify the missing viral load data for KPs, and (2) sample people who were missing viral load data to estimate viral suppression for those populations. The Society Against Sexual Orientation Discrimination facilitated the two stages of the study with technical oversight by MEASURE Evaluation in close collaboration with NAPS. The study took place in early 2019 at five health facilities in Georgetown, Guyana.

The results of the study will help inform MOPH programs both for HIV-positive clients who are KP members and those who are not. It will illuminate gaps in data and show how viral load estimation can be improved at the health facility and national levels.